Published online: 2019-09-23

Review Article
Failure of endodontic treatment: The usual suspects
Sadia Tabassum1, Farhan Raza Khan1

Correspondence: Dr Sadia Tabassum 1

Operative Dentistry, Aga Khan University Hospital,
Email: sadyatabassum@gmail.com Karachi, Pakistan

ABSTRACT
Inappropriate mechanical debridement, persistence of bacteria in the canals and apex, poor obturation quality, over
and under extension of the root canal filling, and coronal leakage are some of the commonly attributable causes of
failure. Despite the high success rate of endodontic treatment, failures do occur in a large number of cases and most
of the times can be attributed to the already stated causes. With an ever increasing number of endodontic treatments
being done each day, it has become imperative to avoid or minimize the most fundamental of reasons leading to
endodontic failure. This paper reviews the most common causes of endodontic failure along with radiographic examples.

Key words: Endodontics, periapical periodontitis, root canal therapy

INTRODUCTION of any infected pulp tissue so the canal space can

Endodontic treatment is fairly predictable in nature
with reported success rates up to 86–98%.[1] However,
there has not been a consensus in the literature
upon a consistent definition of “success” criteria
of endodontic treatment. Likewise “failure” has
variable definitions. It has been defined in some
studies as a recurrence of clinical symptoms along
with the presence of a periapical radiolucency.[2] An
endodontically treated tooth should be evaluated
clinically as well as radiographically for its root canal
treatment to be deemed successful. Patient should
be scheduled for follow ups to ascertain that the
treatment is a success and the tooth in question is
functional. Myriad of factors have been implicated in
the failure of endodontic treatment. The usual factors
which can be attributed to endodontic failure are:
• Persistence of bacteria (intra-canal and extra-canal)
• Inadequate filling of the canal (canals that are
poorly cleaned and obturated)
• Overextensions of root filling materials
• Improper coronal seal (leakage)
• Untreated canals (both major and accessory)
• Iatrogenic procedural errors such as poor access
cavity design
• Complications of instrumentation (ledges,
perforations, or separated instruments).
The aim of endodontic treatment is thorough
debridement and cleaning of the root canal system
be shaped and prepared to be filled with an inert
material thus preventing or minimizing any chances
of reinfection. However, failure ensues when the
endodontic treatment falls short of the standard
clinical principles.[3]
PERSISTENCE OF BACTERIA
One of the foremost causes of endodontic failure
is persistent microbiological infection. [4] The role
of bacteria in periradicular infection has been well
established in literature and endodontic treatment
will be afflicted with a higher chance of failure if
microorganisms persist in the canals at the time of
root canal obturation.[5] Bacteria harbored in root
canal areas such as isthmuses, dentinal tubules and
ramifications may evade disinfectants.[6] A study
performed by Lin et al. on 236 cases of endodontic
treatment failures found a correlation between the
presence of bacterial infection in the canals and
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How to cite this article: Tabassum S, Khan FR. Failure of endodontic
treatment: The usual suspects. Eur J Dent 2016;10:144-7.
DOI: 10.4103/1305-7456.175682

144 © 2016 European Journal of Dentistry | Published by Wolters Kluwer - Medknow

 Tabassum and Khan: Endodontic failure
periradicular rarefaction in endodontic failures.[7]
Bacteria present in the periradicular area will be
inaccessible to disinfection procedures. Canals with
negative cultures for bacteria are said to have higher
success rates as opposed to those canals which test
positive.[8] Treatment is more likely to fail in these
teeth with pretreatment periradicular rarefactions
than those without these radiographic changes.[9]
Other than improper debridement of the canal, a leaky
apical seal is also a contributory factor in endodontic
failure due to microbiological persistence.[4] Seepage
of fluids is likely to occur if apical seal is not properly
established. This can perpetuate periradicular
inflammation anytime. The chances of a favorable
outcome are invariably higher when an affective
cleaning of the canal has been undertaken. Thus
the importance of thorough debridement cannot be
over emphasized [Figure 1a and b].
INADEQUATE OR OVEREXTENDED
ROOT FILLING
Apart from proper disinfection and debridement of
canals, another factor which is of colossal importance
is the quality of obturation. The quality of root canal
obturation was the most important factor in the success
of the endodontic treatment in a study carried out
on 1001 endodontically treated teeth.[10] In another
study which assessed teeth with endodontic failures,
65% of the cases exhibited poor quality obturation
whereas 42% of the teeth had some canals which were
left untreated.[11] Success rates are naturally lower for
obturations which are under or overextended and
are highest for those which end flush or within 2 mm
of the apex.[12] According to a study,[13] overextended
a b
Figure 1: (a) Endodontic treatment in this patient failed due to a leaky
apical seal which resulted in a persistent periapical radiolucency.
(b) Retrograde endodontic treatment was done to seal the apices so a
favorable environment can occur for the healing of the infection
European Journal of Dentistry, Vol 10 / Issue 1 / Jan-Mar 2016
obturation is 4 times more likely to fail than under
obturated canals. In the presence of an existing
periradicular lesion, an overextended root canal filling
will have a worse prognosis than a tooth without excess
filling material.[9] Moreover in a study,[14] an association
was found between increased incidence of periapical
periodontitis and inadequate or overextended root
fillings. However paradoxical results were reported
in a study by Lin et al., in which the apical extent of
the root fillings did not seem to have any significant
correlation with treatment failures[7] [Figure 2a and b].
IMPROPER CORONAL SEAL
A well-sealing coronal restoration is essential after
the completion of obturation as it would prevent the
ingress of any microorganisms, which are present in
the ambient environment.[15] Swanson and Madison[16]
emphasized in their study that coronal leakage
should be considered as a potential factor resulting in
endodontic failure. The importance of a good quality
coronal restoration was also emphasized by Ray
and Trope in their study[17] and later, their work was
replicated by another retrospective study performed
on 1001 endodontically treated teeth.[10] The results
of this latter study showed that success rates of the
teeth with poor quality coronal restorations fell in
contrast to teeth with good quality obturation and
coronal restorations. However the main determining
factor in the success of the root canal was proved to
be the quality of the root canal filling in this study
rather than the quality of the coronal restoration.
Nevertheless, an impervious seal at the coronal area
is vital for a successful prognosis of an endodontically
treated tooth [Figure 3]. Ng et al., in their meta-analysis
stated that pooled success rate for teeth which have
satisfactory restorations is higher than those teeth
which have poor quality restorations.[8]
COMPLICATIONS OF INSTRUMENTATION
Rotary instruments tend to fracture in the canals
when either laws of access cavity preparation are not
a b
Figure 2: (a) The success rate is reduced: With overextended obturation.
(b) And under extended obturation
145
 Tabassum and Khan: Endodontic failure

adhered to or guidelines regarding the use of rotary

instruments are not followed. As a consequence
of fracture, the access to the apical portion of
the root canal is decreased and this could have a
deleterious effect on canal disinfection and later
on, on obturation. Most of the studies done on the
effect of fractured instruments have demonstrated
the minimal influence on the success rate of the
treatment. [9,18,19] The stage of instrumentation at
which the instrument breaks can have an effect on
the prognosis. The disinfection and obturation of
the part of canal distal to the fractured instrument
becomes difficult possibly leading to the presence
of persistent infection in that area. [19] However,
the fractured instrument itself has less to do with Figure 3: Improper coronal seal along with under extended obturation
failure because most of the times, the success is has played havoc resulting in periapical periodontitis
only affected when a concomitant infection is
present.[3] A clinical investigation on relationship
of broken rotary instruments to endodontic case
prognosis confirmed that in the absence of any
preoperative infection and periradicular changes,
a separated instrument is most likely not to affect
the prognosis.[20] Hence it would be very rare that
the fractured instrument is directly involved in
endodontic failure [Figure 4a and b].

UNTREATED CANALS a b
Figure 4: (a) File separated in apical third of the mesial canal of a
It is not an uncommon practice to miss a canal while mandibular molar. (b) The tooth is asymptomatic after a follow-up
after 2 years
carrying out endodontic treatment especially in molar
teeth where one root, one canal formula is frequently
over ruled by the fact that number of canals are more
than the number of roots. Moreover, a less than
adequate access opening makes it difficult for the
primary dentist to locate the supplemental canals.
The inability to treat all the canals is one of the causes
leading to endodontic failure. Bacteria residing in
these canals lead to the persistence of symptoms.
a b
The results of one study carried out on 5616 molars
Figure 5: (a) Patient remained symptomatic after the treatment of
which were retreated showed that failure to locate the maxillary first molar. (b) On follow-up visit, mesiobuccal 2 was located
MB2 canal had resulted in a significant decrease in and obturated
the long-term prognosis of those teeth.[21] In another
prospective study carried out by Hoen and Pink,[11] the success. Regular follow ups aid in assessing the
the incidence of missed canals were reported to outcome and should be done at least on a yearly basis to
be 42% of all the 1100 endodontically failing teeth monitor any changes. However clinical thoroughness
[Figure 5a and b]. during the treatment phase can potentially benefit the
clinician and the patient in the long run.
CONCLUSIONS
Financial support and sponsorship
To sum it up, these “usual suspects” should be kept Nil.
in mind while carrying out the endodontic treatment.
Giving attention to details not only improves the Conflicts of interest
finesse of the endodontic quality but also maximizes There are no conflicts of interest.

146 European Journal of Dentistry, Vol 10 / Issue 1 / Jan-Mar 2016

 Tabassum and Khan: Endodontic failure
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